Medical History "*" indicates required fields Full Name* Sex*MaleFemaleHome PhoneWork PhoneCell PhoneEmail Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Driver's License Number StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificExp Date MM slash DD slash YYYY Social Security # Date of Birth* MM slash DD slash YYYY Employer InformationEmployer Name & AddressEmployer PhoneSpouse's Name PhonePrimary Care / Referring Physician PhonePrevious Dentist PhoneHave You Seen Dr. Orozco Before?YesNoWhom may we contact in the case of an emergency? PhoneWhom may we thank for referring you to us? PhoneHad you heard of Thomas Dental prior to being referred? Who is responsible for this bill? Insurance InformationName of Insured Relationship to Patient Birth Date MM slash DD slash YYYY Social Security Number Name of Employer Office PhoneInsurance Company Group # Employer ID # Insurance Company Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Secondary Insurance InformationName of Insured Relationship to Patient Birth Date MM slash DD slash YYYY Social Security Number Name of Employer Office PhoneInsurance Company Group # Employer ID # Insurance Company Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Medical HistoryDo you have or had any of the following AIDS Anemia Arthritis/Rheumatism Artificial Heart Valves Artificial Joints Asthma Back Problems Bleeding Abnormalities Blood Disease Cancer Chemical dependency Chemotherapy Circulatory Problems Congenital Heart Lesions Cortisone Treatments Diabetes Epilepsy Fainting Glaucoma Headaches Heart Murmur Heart attack Heart Problems Hemophilia Hepatitis High blood pressure HIV Kidney Disease Liver Disease Mitral Valve Prolapse Pacemaker Psychiatric Care/Problems Radiation Treatment Respitory Disease Rheumatic Fever Shortness of breath Skin Rash Sinus Problems Stroke Thyroid Problems Tobacco Habit Positive Tuberculosis Are there any other health conditions you have that are not listed?Please list all allergiesPlease List all medications you are takingDate of Last Exam MM slash DD slash YYYY Reason for Today’s Visit Women OnlyAre You Pregnant?YesNoNursing?YesNoHad an exposure to HPV?YesNoCommentsThis field is for validation purposes and should be left unchanged. Δ
